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Claim Form - Cornish Mutual

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					Cornish Mutual                                                         For office use only     Ref no.



Personal Accident and Sickness
(Farmworkers) Claim Form
Please complete the following sections and return to Cornish Mutual.
The settlement of a valid claim will be made on the basis of your Policy wording.
                                                                          2.5   How long had this employee worked for you
1. Your details
                                                                                immediately prior to this period of absence?
    Please complete this section for all claims

    1.1   Your Member reference number or Policy number                   2.6   What is the continuous length of service of this
                                                                                employee? If there has been any break in service
                                                                                please provide the dates
    1.2   Name

          Address




                                                                          2.7   How many days per week does this employee
                                                                                normally work for you?

          Postcode
                                                                          2.8   What gross amount, before any deductions,
          Home telephone
                                                                                do you pay this employee per week?
          Business telephone                                                    £
          Email                                                           2.9   Was the employee on leave or holiday when injury or
          Date of birth                                                         illness occurred?                         Yes            No
                                                                                If ‘Yes’ on what date were they due to return to work?
          Business or occupation

                                                                          2.10 Had any leave or holiday for this employee been agreed
                                                                                by you for any of the period covered by their incapacity?
                                                                                If so please provide the relevant dates
2. Details of the employee who
   has suffered sickness or injury
    2.1   Employee’s full name


    2.2   Employee’s Date of birth dd/mm/yyyy
                                                                          2.11 Did you have any other employees off work due to
                                                                                illness or injury during the period of this employee’s
    2.3   What Grade of Worker is this employee as defined by                    period of incapacity?
          the Agricultural Wages Act?

                                                                          2.12 Please state the amount of Statutory Sick Pay
    2.4   What type of worker is this employee e.g. regular                     which you have recovered, or anticipate recovering,
          whole-time, flexible whole-time, flexible part-time,                    from the Government with respect to this employee’s
          regular part-time or other, as defined by the Agricultural             period of absence
          Wages Act?                                                            £

                                                                          2.13 To your knowledge is your employee pursuing, or
                                                                                considering pursuing, a claim for ‘damages’ for their
                                                                                sickness, or injury, against someone other than you?
                                                                   4.3   State date from which your employee was first unable
3. Accident
                                                                         to work for you
  Please complete this section if your claim is for accidental
  injury, otherwise go to Section 4

  Please note that for a claim to be considered the
  accidental injury must have occurred in the course
                                                                 5. Evidence of accident or sickness
  of your employee’s work for you, or whilst travelling            Please complete this section for all claims.
  to or from his place of employment with you.
                                                                   5.1   Please provide your employee’s doctor’s certificate(s)
  3.1   Date, time and place of accident                                 (or a photocopy) for the accident or sickness for
        Date                               Time                          which you are claiming under this Policy

        Place

  3.2   Details of injury                                        6. Additional Information box
                                                                    Please add any additional information to support
                                                                    the claim here


  3.3   State fully how the accident occurred




4. Sickness
  Please complete this section if your claim is for sickness,
  otherwise go to Section 5

  Please note that for a claim to be considered
  the sickness must not have occurred as a result
  of an injury outside of your employee’s work
  environment with you.

  4.1   State when sickness first commenced



  4.2   State fully nature of sickness




  Don’t forget to complete the details and declaration overleaf…
Continued from overleaf…


7. Your declaration
      I declare that the statements made are true to the best of my knowledge and belief.

      I declare that I have consent from the employee detailed in this claim form to provide the details given some of which may be
      considered sensitive data.

      Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Ltd (IDS) Ltd.
      The aim is to help insurers to check the information provided and also to prevent fraudulent claims. When you provide
      information about an incident which may or may not give rise to a claim, information relating to that incident may be passed
      to the register.

      I understand that you may seek information from other insurers to check the answers I have provided are correct.

      Signature of Policyholder

      Date




Please detach this form from the “how to complete this claim form” details and return it with any supporting
paperwork to the Claims Department, Cornish Mutual, CMA House, Newham Road, Newham, Truro, TR1 2SU




The Cornish Mutual Assurance Co Ltd                      Tel   01872 277151
Registered office: CMA House, Newham Road,                Fax   01872 263032
Newham, Truro TR1 2SU. www.cornishmutual.co.uk           Email claims@cornishmutual.co.uk

This claim form is liable to alteration from time to time (this version, July 2012 – cancelling all
previous issues).To help us improve our service, calls to our office may be recorded and monitored.

Authorised and Regulated by the Financial Services Authority. Registered in England No 78768
Our commitment
to you
As a mutual organisation we are member-centred                When corresponding with us by email please note
and seek to give a high level of service at all times.        that proof of sending an email does not mean we have
                                                              received it. Please ensure we acknowledge receipt of
We want to make sure that claims are treated fairly,
                                                              your email and contact the claims department
investigated promptly and that our customers are
                                                              Tel: 01872 277151 or Fax: 01872 263032 if an
provided with clear guidance on the claims process
                                                              acknowledgement is not received.
and where relevant why a claim is rejected or not
settled in full.
We aim to respond to a received claim within five
business days or less.
We will do everything possible to deal with your claim
to your satisfaction but if any problems do occur please
write to the Managing Director, Cornish Mutual, CMA
House, Newham Road, Truro, TR1 2SU, Tel: 01872 277151
Fax: 01872 263032 or email claims@cornishmutual.co.uk




     Please use this box to make notes for your own records




Please detach this section and keep for your records
How to complete                                                                      How to return
this claim form                                                                      this claim form
Please read this section and keep                                                    When you have completed this claim form
                                                                                     please attach any supporting information
it for your records.                                                                 and send it to;
Before completing your claim form please take
                                                                                     Claims Department,
a moment to read through the information below.
                                                                                     Cornish Mutual,
It is important that you do not delay returning your                                 CMA House,
claim form as failure to do so could adversely affect                                Newham Road,
the claim process.                                                                   Newham,
                                                                                     Truro, TR1 2SU.
If you have any other information or documentation
relevant to the incident please include it when you                                  As soon as we receive your claim form
return this form. If you are waiting for information                                 we will start processing your claim.
please return the claim form first and send on the
supporting information at a later date. This will enable
us to start processing your claim as soon as possible.
Please help us to deal with your claim efficiently
either by quoting your Member reference number
or your Policy number on all correspondence and/or
Cornish Mutual’s claim reference when issued.
If you need more space to answer a section of the form
please supply this on a separate piece of paper quoting
your Member reference number or your Policy number.
If you have any queries regarding how to complete your
claim form please do not hesitate to contact the claims
department Tel: 01872 277151, Fax: 01872 263032
or email claims@cornishmutual.co.uk who will
be happy to help you.
Please read this section and the important
information overleaf, detach and keep for
your records.




The Cornish Mutual Assurance Co Ltd                     Tel   01872 277151
Registered office: CMA House, Newham Road,               Fax   01872 263032
Newham, Truro TR1 2SU. www.cornishmutual.co.uk          Email claims@cornishmutual.co.uk

This claim form is liable to alteration from time to time (this version, July 2012 – cancelling all
previous issues). To help us improve our service, calls to our office may be recorded and monitored.

Authorised and regulated by the Financial Services Authority. Registered in England No 78768

				
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